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DocuSign Envelope ID:95ED4E50-2135-4421-9D73-64AF3CA1B6D8 <br /> TRAVELERS WORKERS COMPENSATION <br /> AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 <br /> ENDORSEMENT WC 00 03 13 (00)- 001 <br /> POLICY NUMBER: UB-5J675688-18-42-G <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br /> enforce our right against the person or organization named in the Schedule. (This agreement applies only to the <br /> extent that you perform work under a written contract that requires you to obtain this agreement from us.) <br /> This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. <br /> SCHEDULE <br /> DESIGNATED PERSON: <br /> DESIGNATED ORGANIZATION: <br /> ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED <br /> BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS <br /> WAIVER. <br /> DATE OF ISSUE: 09-29-17 ST ASSIGN: PAGE 1 OF1 <br />